The Affordable Care Act Is Not Remotely Similar to the Heritage Plan

As long-time readers know and new readers were reminded yesterday, I’ve long been intensely irritated by claims that the Affordable Care Act proves that Barack Obama is a hapless sellout because it was a “Republican plan.” The rather obvious problem with this line of argument is that any non-trivial number of Republicans have been willing to support the “Republican plan” when 1)massive veto-proof supermajorities of liberal Democrats put it on their desk, and 2)that’s it. Republican support for the plan might discredit it if any conservative Republicans ever wanted anything like it to pass, but of course they didn’t. The plan was a decoy, not a “Republican Plan,” so which think tank came up with it is neither here nor there.

But as stepped pryamids points out in comments, I’ve really been burying the lede. While aware that the Heritage Foundation plan was inferior, I’ve played along with the idea that the ACA was in some way comparable to the Heritage plan. But in fact, the two plans are not remotely comparable. Actually reading the famous policy document, it’s striking how little of relevance the plans have in common. Yes, both plans have a mandate, but since any means of comprehensive insurance that didn’t involve eliminating the health care industry was going to have some kind of mandate to prevent a death spiral in the insurance market, so in itself that doesn’t mean much. And this is a major issue, because that’s where the similarities end. As s.p. puts it:

The Heritage plan was an individual mandate for catastrophic coverage with a tax credit to help subsidize it. That’s pretty much it.

[…]

It’s like saying the EITC is a Republican plan because the Republicans proposed capital gains tax cuts and they’re both tax cuts.

And the Heritage plan is actually even worse than that. Where the ACA included a massive expansion of Medicaid, the Heritage plan essentially proposes to apply the principles of welfare “reform” to Medicaid, allowing states more “flexibility” (to reduce coverage) and allegedly helping the poor by eliminating state regulations requiring health insurance to have actual content. (In fairness, it does offer to give tax benefits to people who subsidize the health care of poorer relatives, so the many poor Americans with rich uncles will be in great shape!) It would have taxed health care benefits gained through employment as income, and therefore for all intents and purposes forced middle-class people into an individual market that for the non-wealthy would have offered nothing but crappy, largely unregulated catastrophic coverage. Oh, and it would have voucherized Medicare a la Paul Ryan.

To compare the ACA and the Heritage plan, in other words, is ludicrous. The ACA contains many long-standing liberal priorities — expanding Medicaid, regulating the health care industry, providing substantial subsidies for real insurance — that the Heritage plan manifestly does not. And the Heritage plan includes many horrible ideas that the ACA did not contain. But acknowledging the massive, fundamental differences between the ACA and the Potemkin Heritage plan — differences of kind, not of degree — makes it harder to advance the narrative that the flaws in the ACA result from Barack Obama’s abiding hatred of the very idea of federal intervention into the health care market. If Obama had actually proposed something like the Heritage plan, it would actually be fair to call him a neoliberal stooge. But he didn’t, and the differences between the Heritage plan and the ACA disprove the charge conclusively.

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If here’s to be an honest comparison between Democratic and Republican policy priorities when it comes to health care, we should be using Bill Kristol’s plan because that’s the one Republicans actually follow.

JMP

Though, if you want to be more succinct, the Ron Paul health care plan of “Let them die!” is a completely accurate summary of Republicans’ actual ideas.

Sly

In terms of policy outcomes for people who need insurance, yes. But that’s incidental to conservatives’ desired political outcomes, which is at the center of the their approach to healthcare or anything else. If a policy undermines the rationale for the welfare and regulatory state, it’s a preferred policy. Full stop.

Whether or not that policy actually accomplishes the advertised task (which it usually doesn’t), or is even enacted into law to begin with, is an ancillary concern at best.

Manju

Whoa…there’s been a slew of Health Care posts recently. I ahven’t been paying too much attention, but it appears that Scott is trying to calm down a lot of liberal in distress. Has there been a new development?

Last I checked, the problem is that the website was down. My advice? Wait until they get it up and running. Problem solved.

Warren Terra

You’re out of date: the website is reportedly working fairly well, though there are questions about how well it’s transmitting the data it collects to insurers.

The likely explanation is that so long as the website difficulties predominated the discussion, broader discussions of the topic felt irrelevant to the sharply focused problem at hand. Ideas for such discussions thus accumulated and are now being posted.

Murc

I ahven’t been paying too much attention, but it appears that Scott is trying to calm down a lot of liberal in distress.

Or, the more likely scenario: the fact that people keep getting these basic facts wrong is one of Scott’s longstanding hobby horses because he finds it personally distressing that so many liberals proceed from incorrect assumptions when trying to determine a path forward; a bad starting point will make it that much harder to determine effective political maneuvering in the future. So every time this sort of chatter starts popping up, he beats it down. Hard. Because he’d maybe like people to stop being wrong and start being right.

I could be wrong, of course. I’m not Scott. But this just seems less “calm down, people” and more “for fucks sake, not AGAIN.”

Scott doesn’t have a monopoly on the truth, but wanting everyone to be on the same page regarding basic facts on the ground and getting hacked off when they aren’t is kind of one of the sine qua nons of doing political commentary and analysis. There don’t have to be ulterior motives. “I’m right and you are wrong” is motive enough.

Wrong again

Yes, but I’ve been wrong for years. Why now?

Paula

Or, Scott could be resigned to the fact that people on the internet are often wrong.

Yeah, I’m cranky.

Every time Scott lays out the case in various ways, I feel like its all so straightforward.

But it’s like the lefty version of “keep your govt hand off my Medicare” rant. No one cares that Joe Lieberman was an ass, no one cares that there were no 60 votes for the public option, no one cares that Barack Obama doesn’t actually control Senate chairs, and suddenly Congress is a non-entity in passing laws.

It ain’t fucking 11-d chess, it’s trying to win a numbers game.

oldster

I think the dynamic may actually have to do with a perverse reactions to winning.

So long as it looked like the ACA was screwed, liberals were all like, “but, but, we wanted our ACA so much!”

Now that it looks like it is actually going to turn out okay, liberals have switched to, “stupid ACA! We could have had something ten times better if Obama hadn’t messed it all up!”

I say “liberals”. I should specify. It’s one segment of the extreme end of Obama-hating, firebagger, perfectionists.

Some people can’t stand winning. There’s definitely a subset of “liberals” who’ve become intolerable since Obama took office, and seem really upset that George Bush left; they act like they’d rather be in the minority and fighting the powers that be forever over ever getting a victory. They’ve therefore convinced themselves that somehow Obama is really a secret conservative and just the same as Bush. So this helps justify their trying to get Republicans elected by supporting third-party vanity candidates.

ericblair

If you don’t win, you’re not responsible for the outcome. You can then coulda/shoulda/woulda everything into Unicornland. If the world ever gets worryingly close to tracking what you advocate, well, those goalposts won’t move themselves, so get busy.

Crissa

The website was hardly ever down. It has an up time higher than my bank’s. (BofA, if you need to know.)

Warren Terra

It’s always keeping in mind that while a universal “catastrophic coverage” system isn’t completely nothing, in that a half-decent version would mean those in greatest extremis would have some confidence they’re not going to be abandoned to die – it’s still terrible health policy, incredibly socially regressive, and is not remotely comparable to the ACA nor to any system in the developed world.

“Catastrophic coverage” means that young, healthy middle-class people are fairly safe: they can go without more comprehensive coverage, knowing that their and their families’ assets can if necessary cover the massive deductibles involved. They may even pay for dctors’ visits out-of-pocket: they have the pockets to do so, and they don’t fear utter destitution. But the poor, and indeed those who merely aren’t rather affluent, will be forced to neglect their medical needs until a true emergency has arisen, and will thus receive their care later and at greater need – and with worse outcomes, and likely at greater expense to society, let alone to themselves.

A “Catastrophic Coverage” system is better than prattling about trading chickens for life-saving treatment, and it’s better than letting people die unattended. But it’s a terrible system, nonetheless. And, as Sly notes, that’s even if you take it to have been a serious proposal rather than a distraction, against the evidence it was in fact the latter.

Scott Lemieux

A “Catastrophic Coverage” system is better than prattling about trading chickens for life-saving treatment, and it’s better than letting people die unattended. But it’s a terrible system, nonetheless. And, as Sly notes, that’s even if you take it to have been a serious proposal rather than a distraction, against the evidence it was in fact the latter.

All very true.

LeeEsq

The ACA seems closest to the Bismarckian system in that it requires everybody to have insurance and puts substantial regulations on insurance companies in order to make sure that they don’t attempt to screw the insurance holders when they need it. It puts less regulation on the insurance companies than other Bismarckian systems like the Netherlands or Israel because of the reality of American politics but its about the same system.

I think one reason why a lot of liberals see the ACA as the Heritage Plan system was that many of them saw single-payer as the one, true form of universal healthcare that any other system comes across as inadequate.

The ACA has been described as Heritagesque in both traditional media and liberal blogs. Repeatedly.

Sharon

The reason that many liberals placed the genesis of the ACA in the basement of Heritage was because people like Brad deLong were bragging about how clever the Administration was in getting liberal House members to support Heritage “Lite.” It was a triumph of nonpartisan, technocratic-centrism.

I’ll also note that there is a tax on insurance plans that the law characterizes as high-cost “cadillac” plans, that I believe kicks-in in 2017.

I think that the ACA is better than what we had before, and the Medicaid expansion is a huge boon for people in states that chose to do it, (trust me, I have friends who can now see a physician on a regular basis because of the expansion, they’ll have a chance to make it into their 60s now.) But the PPACA doesn’t strike me as a great leap forward for liberalism just because the Democrats of the 110th Congress passed it. These Democrats aren’t all that liberal.

Cheap Wino

When you consider the degree to which obstructionism has been the Republican congressional modus operandi since 2008, passing ACA is a massive, massive win for Obama. Criticizing it for not being liberal enough is both misguided and utterly pointless.

NonyNony

Criticizing it for not being liberal enough is both misguided and utterly pointless.

No. Vocally criticizing it for not being liberal enough is exactly what needs to be done to move the conversation to the left.

“Criticizing” it by saying that it’s a Republican plan and the Democrats sold us out and we’d be better off if the Democrats had done nothing and … is misguided and utterly pointless. If it were true it would have a point but it’s at best wrong and at worst a lie (depending on who is saying it).

But making an honest critique along the lines of “this is better than what we had before but it isn’t good enough” is exactly what needs to be happening. About every aspect of policy. You don’t sit down and shut up when you start getting what you want in this country – you demand more. That’s the only way you keep your momentum going and keep things moving in the direction you want it to go.

rea

“It’s like saying EITC was a Reppublican plan”

Well the EITC (enacted 1975) was a Republican plan, sort of. It was a early iteration of “welfare reform”, enacteed with the idea of encouraging the poor to stop being welfare queens and work, and of course signed by a Republican president.

Eric

Milton Friedman was down with the EITC.

witless chum

The combination of Naughty by Nature and Milton Friedman is pretty giggle-inducing. Hat off to you, sir or madam.

Ralph Wiggum

Yeah, but in the 1960s and 1970s conservatives had to propose conservative means of solving social problems. When most of the public was potentially receptive to liberal concepts, ‘let them die’ just didn’t cut it. Now they either deny they exist or say that government has no right to/is incapable of resolving them. On the question of how much the earlier position was a tactical ploy, I will let you make up your own mind.

Incontinentia Buttocks

News flash: liberalism, conservatism, and the two major parties have changed over time.

The EITC was originally proposed by Russell Long, who was a Democrat, albeit a Southern Democrat. The initial EITC was fairly small and expanding it since has been a Democratic initiative, particularly in 1986 and 1993.

It’s not the clearest example, I admit. If you prefer, try this: it’s like saying same-day voter registration is a Republican idea because the Republicans are in favor of voting reforms.

Derelict

I think the problem here is that the differences between Obamacare and the Heritage proposal are differences of degree, not of kind. It’s true that none of the Republicans pushing the Heritage proposal back in the ’90s was ever serious about seeing it enacted into law (it was intended to suck oxygen away from “HillaryCare”). However, you can draw a fairly straight line between the Heritage proposal, Romney’s Massachusetts program, and Obamacare.

For this to be meaningful we have to know what a difference in kind is and why it would matter. The Heritage plan and the ACA preserve the private insurance market but so does a plan with a public option. So that’s just a difference in degree? The German system also does this, so is the Heritage plan just a variant of the German system?

Well yes in the sense that they are all insurance based. But this doesn’t tell you much.

Also, we really shouldn’t say “Romney’s MA program”. As people have pointe sour in prior thread, it was passed by overwhelmingly veto proof Democratic majorities which had to override a number of Romney vetos of portions of the plan!

MAJeff

I’m trying to figure out when it became Romneycare. I don’t recall people calling it that when the thing was enacted.

Warren Terra

I only remember the term as a national phenomenon, not a Massachusetts one. But I could be wrong …

MAJeff

Yeah, that’s what I was thinking. I was living in MA during that period, and there was no such term so far as I can remember.

Malaclypse

I remember “Romneycare” being coined around the time “Obamacare” was. I think, but am not sure, that “Romneycare” started as a term of derision by firebaggers for the ACA. But it wasn’t a Massachusetts term back when it was enacted.

MAJeff

I was just playing around with Google trends, and yeah, it doesn’t really start spiking until about 2009.

Yes, and we still dont call it romneycare. That was purely a construct of the national press.

djw

Right. I associated the “Romneycare” tag with the Republican primary. Back in 2006, I seem to remember reading about this neat new thing Mass. was trying, with “oh by the way they even got the Republican governor to go along” as an afterthought.

Malaclypse

I remember people in Massachusetts talking about MassHealth, or the Commonwealth Connector. I remember employers talking about HIRDs, and Fair Share Contributions. I don’t remember any overarching term in common usage at the time, other than sometimes the bland “health care reform.”

And I remember sitting in countless seminars that were pretty much evenly divided between 1) HR people and accountants wanting to learn how to document compliance with the law, and 2) owners of low-wage businesses angry that the damn liberal legislature did this, who wanted to learn how to cheat.

Malaclypse

Just checked – all of the e-mail lists I was on back in 2006-2007 refer to it as “Health Care Reform” or “Health Care Reform Law.”

Malaclypse

Also, the only compliance e-mails that had the name “Romney” in it was about 1) how the legislature overrode his veto to raise the minimum wage, and 2) on his last day in office, he expanded what types of child labor were allowed (no, I’m not making that up). Not a single seminar, e-mail, anything linked the MA law to Romney back then.

MAJeff

Almost everything he did on Beacon Hill showed him to be a cold, petty asshole.

Romneycare was during the 2012 campaign, where this stupid “Obamacare was a Heritage Foundation idea” meme got started, and connected to it. The ultimate source is Romney’s attempted circle-squaring with respect to the Massachusetts program, which took its final form after the legislature overrode Romney’s veto of its most important element, the EMPLOYER MANDATE. Since the program is immensely popular, Romney took credit for it although he had of course attempted to destroy it and continued to oppose its fundamental principles.

Rather than calling him out for this, which would have required a minimal understanding of what’s actually in the Massachusetts program, the ACA, and the Heritage proposals, Our Liberal Press went with the lazy option of saying it’s all the same stuff and arguing about it is just “partisan”.

That’s what’s maddening about it, too. The ACA is in fact an astonishing piece of progress given the stupidity of the current intellectual climate and deserves to be recognized. No, it’s not single-payer, and Obama is no more a socialist than that deficit hawk FDR was, but it sets up the preconditions for single-payer (see Vermont) and meanwhile saves millions of lives.

IM

The ACA doesn’t imitate the german system , but rather the dutch and swiss system. The swiss system while more expensive then other systems, works. Of course the ACA is inferior. But with same changes it could work as well as the swiss system. Now the american political realities make these changes impossible, but that is not a special ACA problem.

Well, at the level that “Heritage plan is merely different in degree from the ACA” I think is fair to say that “the ACA is merely different in degree from the German system” or for that “German and English aren’t different in kind, merely in degree; you can draw a straight line between German and English!!”

IM

No. The swiss and ACA system is obligatory private insurance, regulated and subsidized, health care done by private providers.

the german system is obligatory public insurance health care done by private providers.

the british system is health care done for everybody done by one public provider.

My point is that if you are willing to say that re difference between the ACA and the Heritage plan are not significant then you’re as obtuse to significant distinctions as someone who says that the ACA and German systems are the same.

I’m sorry you completely misunderstood this thread. But you did. I understand the differences between the ACA and the German systems and their gap was central to my point.

All salaried employees must have public health insurance. Only public officers, self-employed people and employees with a large income, above c. €50,000.00 (adjusted yearly), may join the private system.

(And this is my point. You’d only think this is the same as the ACA if you ignored all sorts of key differences. Similarly, you can only think the ACA is the same as the Heritage plan if you ignore key difference.)

IM

Have I claimed something different?

And if you say that is indeed central to my point once more, you risk turning into Jonah Goldberg.

the british system is health care done for everybody done by one public provider.

Oh, and this isn’t true at all. GPs are generally, as I understand it, not employees of the government:

Nearly all hospital doctors and nurses in England are employed by the NHS and work in NHS-run hospitals, with teams of more junior hospital doctors (most of whom are in training) being led by consultants, each of whom is trained to provide expert advice and treatment within a specific specialty. But most General Practitioners, dentists, optometrists (opticians) and other providers of local health care are almost all self-employed, and contract their services back to the NHS. They may operate in partnership with other professionals, own and operate their own surgeries and clinics, and employ their own staff, including other doctors etc. However, the NHS does sometimes provide centrally employed health care professionals and facilities in areas where there is insufficient provision by self-employed professionals.

(But that’s really a distinction that doesn’t matter I think. The distinction between self employed contracters vs. public employees in the UK at least doesn’t affect most things. It’s been a bit of a danger as the Tories want to use that as the wedge of full blown privatisation, but the GPs themselves resist that.)

IM

By it isn’t true at all you turn GP into the norm of providers. That is much worse simplification than my own.
And all this to defend a stupid rhetorical device.

If what you meant is that by saying “it’s not true at all” I’m committed to something like “90% of providers are GPs”, well, then, you’ve obviously wrong. All that’s needed in that they make up an appreciable part of the system, which they do! Or let’s consider this document:

The key difference between the countries lies in the role of the internal market. England and Northern Ireland have a ‘purchaser/provider split’, whereby one part of the health service (the purchaser) is responsible for contracting with the NHS and independent-sector organisations (the providers) to supply services for patients. Scotland and Wales have moved away from these market-orientated models since devolution: they dismantled the purchaser-provider split in 2004 and 2009 respectively. Local health boards in these countries are now responsible for both funding and provision of NHS services.

Turning GPs into employees would be a very large shift in the NHS.

That is much worse simplification than my own.

Sigh. I think at this point you’re just being culpably obtuse.

But by all means, carry on!

(If you wanted to do something useful, articulating with actual precision what sorts of difference are significant in some principled way would be useful. I stand by my assertion that if you can blur the ACA and the Heritage plan, you can in the same way blur the German system and the ACA. It’s not a rhetorical point. The analytical mode that achieves the one can easily achieve the other. Your analytical mode was to highlight what you thing are differences to the exclusion of the similarities. Either abstraction could be useful in some circumstances, but the similarity based one is problematic here because it’s being used to conflate two systems for the sake of denigrating one. Yours isn’t useful in this context because you are using it to…well, complain about me inaccurately.)

Scott Lemieux

I think the problem here is that the differences between Obamacare and the Heritage proposal are differences of degree, not of kind.

They really aren’t. The plans are radically different.

Tom Servo

Oh come on Scott you follow the legal system. Every 1L doing moot court knows that any two things, taken to the highest level of abstraction, are similar.

In a desperate effort to prove his Obot/DC Comics point, Lemieux is clearly ignoring the fact that the Heritage plan would’ve been pushed substantially to the left by Senate Democrats of the time, such as Richard Shelby, and good faith liberal critics, like the Andrew Sullivan era New Republic. QED, suck it.

Who “would’ve” introduced the “Heritage plan” to the Senate? It was never an actual proposal, merely a way of opposing the Hillary Clinton-Ira Magaziner plan. The only thing Shelby ever “pushed to the left” was the Democratic party, when he left it.

The Heritage white paper was published in 1989 so I don’t see how it was “a way of opposing the Hillary Clinton-Ira Magaziner plan”. The WSJ recently reminded the Heritage guy (Stuart Butler) of this; Butler is trying to excuse his now-heretical support for TEH MANDATE by claiming that his plan was just an alternative to HillaryCare. But it predated the Clinton plan by a couple years at least.

Great post.

Ron Fournier

I am very ready to admit that I was too pessimistic about ACA. It’s already offering more affordable plans to more people, AND holding down the growth of health-care costs more effectively, than I predicted. (And that despite all-out Republican sabotage efforts.) It’s not where we need to end up, but it’s going to be a genuinely useful step along the road.

Steve LaBonne

Oops, that was me. The real Ron Fournier would never say anything good about an Obama achievement!

politicalfootball

The Heritage argument was one made by both liberals who criticize Obamacare and conservatives who supported it, and as Scott says, both were wrong.

However, similar arguments were deployed, for somewhat different reasons, about Obamacare’s similarities to Romneycare. My question to the assembled experts: How valid is that comparison?

joe from Lowell

Very valid.

Keep in mind, though, Romneycare represented the outcome of a negotiating process dominated by a powerful Democratic Party, led by Ted Kennedy. It’s not as if the Massachusetts health care system was anything close to what Mitt Romney actually wanted.

Malaclypse

I’ve dealt with compliance for Romneycare (which would be more accurately known as “Travaglinicare”) since its introduction. So:

1) Overall, quite valid.
2) Non-discrimination rules under Obamacare are a lot stricter, due to the way ERISA is expanded. This is a big deal. Anyone remotely clever could use subsidiary companies to drive a truck through MA’s non-discrimination. ERISA, however, has teeth, and violating ERISA leaves owners/officers potentially personally viable for criminal, not just civil, penalties.
3) “Affordability” is a lot stricter. MA merely mandates that the employer pay 33% of the individual premium, the ACA has the 9.5% rule. This is a big difference.
4) Full-time is now 30 hours, not 35. There are strict rules for how to deal with people who have variable hours, while MA was more of a “good-faith” estimate.
5) The Commonwealth Connector works a lot better than Healthcare.gov, but that is because we didn’t have organized groups trying to fuck our exchanges up.
6) Rules for compliance were a lot clearer for MA. At this point in the process then, I knew exactly what I needed to do not to break any rules. The ACA has enough moving parts/deadlines that I am genuinely concerned I’ll miss some detail and not be in compliance.
7) That non-discrimination thing in point 2? Delayed a year, along with most of the employer mandate. I suspect that this part will go away, and agree with Ezra that it should. Employer-based health care is a stupid relic of World War 2 wage controls. Let it die. Use the exchanges to build something better. Those exchanges are potentially the building blocks of government-provided health insurance. The US will always let the rich buy better coverage, which means we will never get true universal single-payer. But those exchanges can be a government-provided floor, and that is a Damn Good Thing.

Malaclypse

Oh, and 8) MA applied to companies with 11 or more employees, while the ACA was 50 or more. That is one of the very few ways that MA was stricter for employers than the ACA is.

cpinva

” The US will always let the rich buy better coverage, which means we will never get true universal single-payer.”

don’t agree. the one has zip to do with the other. single-payer would allow anyone that wants to to purchase additional coverage from the private market.

Malaclypse

Which means that health care has more than one payer. You have the government paying, say, 95% of the costs, and rich-person-insurance paying the others. Still multiple payers.

Tom Servo

Yeah so that would technically be public option. But in your scenario, if the government is paying 95% of costs then there isn’t much meaningful private sector competition is there? So doesn’t not calling it single payer become a little formalistic? I dunno, I would be on cloud nine if we ever got there, I don’t think we absolutely need or can get pure single payer.

England has a private sector in health care providing a lesser set of treatments than those obtainable from the NHS[citation needed]. Private health care is sometimes funded by employers through medical insurance as part of a benefits package to employees though it is mostly the larger companies that do. Insurers also market policies directly to the public. Most private care is for specialist referrals with most people retaining their NHS GP as point of first contact.

Germany seems to have a tighter distinction. From what I can tell, it’s pretty hard to get onto private and even harder to switch back.

However, I’d be less willing to call Germany single payer as something like 15% is private insurance. NHS, it’s pretty close to 100%.

Ian

If Obamacare means the exchanges and the personal mandate, then obviously there are strong similarities (but as JfL says, it wasn’t really Romney’s plan). But while I take Malaclypse’s point about the progressive potential of the exchanges, the more immediately important thing about OCare is the Medicaid expansion, which of course has no parallel.

The expansion is a straightforward, old-fashioned welfare plan: the government offers healthcare to a much larger section of the population and finances it by taxing rich people. Almost 1.5 million new people have signed up for Medicaid since the exchanges opened, and that’s just the beginning. This is a big fucking deal.

The fact that Roberts acquiesced to the exchanges but did all he could to hamper the Medicaid expansion (save overturning the entire law) speaks volumes about its significance.

Malaclypse

the more immediately important thing about OCare is the Medicaid expansion, which of course has no parallel.

MassHealth is a pretty direct parallel to the Medicaid expansions.

Ian

Did MA expand MassHealth on its own on a scale similar to what OCare is now doing? (That’s a real question, I don’t know anything about it.)

Malaclypse

I’ve never experienced it as a user, but that is pretty much my impression. Except anecdata tells me that the quality of coverage is better. But this I’m not an expert on.

ploeg

One should not neglect to point out, however, that under current definitions, the Heritage plan would be socialism.

politicalfootball

Only if Obama proposed it.

junker

If Heritage was smart, they’d draw up a generous single payer plan and get a hapless Republican to endorse it. Then single payer would forever be dead for the left.

NonyNony

Nononono – don’t confuse the “left” that makes dumb arguments like “Republicans supported something that looks vaguely like this so I hates it” with the “left” as represented by politicians in Congress.

Even a tepid single-payer plan offered up by a Republican would be hailed by 3/4ths of the Democrats in Congress as a bold step towards bipartisanship. The remaining 1/4 would be conservative Dems confused by the sudden movement of a Republican and unsure of exactly which way they should move…

junker

Yeah, I should have more explicitly said something like “Firebaggers.” Too broad a brush and all that :)

DrDick

I actually feel better now, having read this. It has long bothered me to think that the infamously regressive Heritage Foundation had proposed so many nominally progressive initiatives.

Anna in PDX

Me too. I honestly had heard both the Heritage argument and the Romneycare argument so many times that I really thought they were true.

gman

“It’s like saying the EITC is a Republican plan because the Republicans proposed capital gains tax cuts and they’re both tax cuts.”

Milton Friedman was a huge proponent of ETIC.

gman

EITC

gman

For such a “radical” plan it is surprising healthcare stocks parabolic?

Incontinentia Buttocks

Thanks for this, Scott.

The ACA is simulataneously a real step forward, the best plan that could have been accomplished given where things stood politically at the time of its passage, and a maddeningly complicated, Rube Goldberg device that provides far too many points for GOP monkeywrenching. Though I’ve supported it from the start, its problems are real.

But good to know that the Heritage Plan meme is inaccurate.

Rob in CT

The whole thing got started because of the freakout over the mandate. The point was that the Heritage plan had a mandate. Over time that morphed into “it’s just like the Heritage Plan” which, ok, isn’t really so. It is closer to Romneycare, which also has a mandate.

This is hairsplitting, IMO.

IM

No. The heritage plan seems to be about half of what ACA created. At some point a difference in degree is a qualitative difference.

Dan Nexon

My understanding is that Heritage Foundation employees worked with Romney on the Massachusetts plan. And the point is that the broad contours of the plan were very much something Republicans were on the record of supporting. The fact that the outcome reflects conservative Democrat veto-points rather than ‘moderate’ Republican ones is simply the result of the decision of the GOP to obstruct rather than seriously negotiate.

Now, a major difference is that various Republican individual-mandate plans tended not to include employer mandates. Part of the point was to shift the burden of health-insurance coverage *away* from employers onto individuals. Some technocratic liberals now prefer this arrangement.

The important Heritage notion is that you should be required to purchase a product that it basically should be illegal to sell for a profit.

But hey, we get it, you like Obamacare. I am pessimistic, but I am waiting and seeing. I did some research on the California website, and it sure looks like the bronze plans are limited to catastrophic care and some small expenses, and even the platinum plans are nowhere close to free health care for everyone, which is the actual policy goal here.

Warren Terra

1) W

But hey, we get it, you like Obamacare.

1) Who is we? Do you each type on half the keyboard? Do some of you dictate to a typist? Are you a royal personage?
2) “like Obamacare“, compared to what? Some other conceivable policy? Some other, unachievable legislation?
3) “like Obamacare”, compared to what? Disliking it? Settling for it? Deriding it? Adoring it?

it sure looks like the bronze plans are limited to catastrophic care and some small expenses

Hey, “we” get it, you have not the faintest idea what other people meant when in the context of healthcare policy they referredto “catastrophic coverage”. Even a Bronze plan covers a lot of moderate and routine expenses in part or even in whole, and makes it feasible to see the doctor when you think you might need to; “catastrophic coverage” plans such as those promoted by the Republican under Clinton only kicked in once you were already out of pocket by something like the median annual household income.

1) Who is we? Do you each type on half the keyboard? Do some of you dictate to a typist? Are you a royal personage?
2) “like Obamacare“, compared to what? Some other conceivable policy? Some other, unachievable legislation?
3) “like Obamacare”, compared to what? Disliking it? Settling for it? Deriding it? Adoring it?

it sure looks like the bronze plans are limited to catastrophic care and some small expenses

Hey, “we” get it, you have not the faintest idea what other people meant when in the context of healthcare policy they referred to “catastrophic coverage”. Even a Bronze plan covers a lot of moderate and routine expenses in part or even in whole, and makes it feasible to see the doctor when you think you might need to; “catastrophic coverage” plans such as those promoted by the Republican under Clinton only kicked in once you were already out of pocket by something like the median annual household income.

Scott, I don’t think the point of the health care system is to prevent bankruptcy. It’s to equalize the unfairness of people having to pay for the bad luck of having health conditions. Obamacare requires everyone to buy policies that keep people out of bankruptcy but saddle them with huge costs, AND penalize employers who give employees comprehensive coverage.

You can’t go on calling everyone whp disagrees with you stupid. I am willing to give this law a chance. But the policy I favor is FREE health care. And this looks like fairly expensive, high deductible health care.

Again, you’re comparing the ACA to the wrong baseline. To anyone who knows anything about American politics, there’s nothing remotely “shocking” about the failure of the federal government to eliminate the health insurance industry. It’s blindingly obvious that any comprehensive health care reform in the United States is going to have to be along the lines of the Swiss and Dutch models.

But the policy I favor is FREE health care. And this looks like fairly expensive, high deductible health care.

Actually, you don’t. Your offer to the uninsured between the ages of 18 and 55 is exactly the same as the Republican one: “nothing.” That you would enact an NHS if you were the Prime Minister of the United States is utterly irrelevant to any meaningful policy debate taking place in the United States.

You seem utterly unable to distinguish between normative and empirical arguments. There’s not actually any dispute between us that the British, Canadian, or French systems would be superior to the ACA. But since you’d have to be dreaming in technicolor to think that any of the latter three are viable possibilities it’s beside the point in this context.

Warren Terra

No. This is a mechanism that everyone at least have half-decent insurance, and that if they need help to pay for it the help is there, and that they can also get better insurance if they want, with help from government money.

Some key points:
1) health insurance obtained on the individual market before the ACA was a total fraud. Because of Preexisting conditions and Rescussion, it was meaningless.
2) the minimal standards for ACA compliant plans are inferior to those elsewhere in the developed world, and to your past employer-provided plans. But they’re not terrible, and they’re a huge improvement on the plans companies were selling that had bigger copays, bigger deductibles, and annual and lifetime benefit caps.
3) as you appear by omission to concede, “catastrophic coverage” ideas were dreadful even by the standards of non-ACA-compliant plans. They were a roadmap to medical bankruptcy and terrible public access to maintain health.
4) the ACA is a big kludge that preserves the interests of millions of Americans who work in or have invested in the insurance industry. It’s a clumsy, terrible design that (a) is predicted to get the job done, for the first time in a century; (b) managed to become law, despite all the forces arrayed against it and in a process requiring the grudging acquiescence of Joe Lieberman and others; and (c) yes, no-one would design from scratch.

Now go back and play in your fantasy world, it’s clearly where you truly live.

As I said, I am willing to give this law a chance. But you are apparently too stupid to understand that saying “this is the best that could pass” is not the same as “this will do anything to make health care free for Americans who need it”.

From my standpoint, this is keep Americans barely afloat insurance, and true free health care from employers is taxed out of existence.

Scott Lemieux

“this will do anything to make health care free for Americans who need it”.

You have argued very persuasively against the zero people who have ever argued that this will be the result of the ACA!

true free health care from employers is taxed out of existence.

“I’ve got mine, fuck you” is not actually much of a progressive credo.

Warren Terra

“this is the best that could pass” is a ringing endorsement. If it is accurate, and I think it is, it’s cause for celebration, not lamentation.

And: if you purport to opine on health policy and yet want to protect our pre-existing system of employer-provided health care, you are being breathtakingly ignorant, desperately and blindly selfish, or just plain stupid. It is an artifact of WWII wage controls that essentially every expert of every stripe agrees is bad policy.

Malaclypse

it sure looks like the bronze plans are limited to catastrophic care and some small expenses

Again, I reviewed the policies on covered California. The out of pocket costs were huge- higher co-pays and deductibles than I have ever had.

It will prevent a medical bankruptcy, but it doesn’t come close to giving free health care, which should be the goal.

Scott Lemieux

doesn’t come close to giving free health care

Yes, if you compare the ACA to health care reforms that have absolutely no chance of being enacted at any point in the foreseeable future, it will be inferior. If you compare it to the actually relevant policy baseline, it’s a very substantial improvement.

1. I am not even sure Obamacare is an improvement. I don’t think medical bankruptcies were that important, as opposed to people not being able to get care. But I will wait and see.

2. You assume there was no way to expand public provision of health care. But in fact S-CHIP got expanded several times. I am not CERTAIN that better plans could have passed, but you are just being a hopeless Obamabot when you assume they couldn’t. The key is a better plan would have been incremental, such as building federal health centers or further expanding S-CHIP and Medicare and the VA, not universal.

Scott Lemieux

. I don’t think medical bankruptcies were that important

Shorter Dilan Esper: I’ve got mine, fuck you!

such as building federal health centers or further expanding S-CHIP and Medicare and the VA

Leaving aside the idea that creating, say, a Medicare buy-in at 55 would be an adequate substitute for comprehensive health care reform (again, see above), please to be explaining how you get Joe Lieberman’s vote for it when we know he rejected this very policy.

And, of course, the ACA did have a very significant expansion of public health care provision. Which is always ignored in the critiques of middle-class pseudo-left-wing attacks on the ACA, because we’re not on Medicaid so fuck everyone who might be affected.

Medical bankruptcies end in a discharge, Scott. It isn’t great, but the problem is the lack of free health care. having just enough health insurance to be bled dry by co payments is just as outrageous as going bankrupt.

You are redefining the problem and declaring the redefined problem solved.

Warren Terra

Yes: medical bankruptcies end in a discharge. This is true one way or another: death, which is a likely consequence, also discharges debts.

But: getting the medical care you need when it’s going to leave you bankrupt, when there’s little guaranty it will be paid for, is extraordinarily difficult. Look into the troubles of poor people seeking cancer treatment some time! And a system predisposed to medical bankruptcies is terrible at helping people to maintain their health, to get diagnosed and treated early, with a greater chance of success.

What you’re saying is pretty muh the equivalent of those Republicans who ignorantly or mendaciously claim poor people are already OK because of EMTALA.

Paula

omg, you’ve never been seriously sick or known anyone who has been, you lucky duck you.

Jesus Christ.

Warren Terra

Actually, the ACA does a lot to make check ups and some routine procedures affordable, so that people are more likely to maintain their health and to remain productive numbers of society. This is a far cry from merely “preventing medical bankruptcy”; plans that only prevent bankruptcy will see people avoiding medical care for as long as possible.

Bronze plans pay for a few appointments. But anything beyond that costs a ton until the deductible is hit. Working class people can’t afford thousands in co-payments, and you have just required them to buy a crappy product.

Warren Terra

No: i’ve just given them money to purchase something much better than they had before. “Paying for a few appointments”, which you deride, is key to public health. People don’t need to fear seeking medical advice and consultation, because they can afford it, and if the news is bad they’re still covered against truly extraordinary expenses (much, much better covered than under “catastrophic coverage”), and they’re informed enough to act enough to act early and responsibly.

For what I hope is the last time, you heartless purist: the ACA is good only in that it’s about the best bill anyone who’s not a moron imagined could possibly become law, only in that it’s actually working, and only in that for the previous seventy years we got zip. It’s not a policy anyone would make from sratch, it’s too complicated, it’s compromised, it preserves the useless middlemen of the insurance industry – but it will not only save but also vastly improve lives. That’s something your supercilious and ignorant tirades will do nothing for.

Scott Lemieux

Working class people will be substantially subsidized (or Medicaid eligible) and have access to far better health care than they do now.

Scott Lemieux

No: i’ve just given them money to purchase something much better than they had before. “Paying for a few appointments”, which you deride, is key to public health. People don’t need to fear seeking medical advice and consultation, because they can afford it, and if the news is bad they’re still covered against truly extraordinary expenses (much, much better covered than under “catastrophic coverage”), and they’re informed enough to act enough to act early and responsibly.

This. All of this.

joe from Lowell

You assume there was no way to expand public provision of health care

Obamacare includes a massive expansion of public health care through Medicaid, as well as through the billions of dollars for public health clinic funding.

Anonymous

In his pissier moods, Brad DeLong makes this argument, and it drives me crazy. Especially since his wife is a health policy expert. There really is no excuse.

bobh

As most people know, Obamacare is a variation of the Massachusetts plan, which is a variation of the Heritage plan. The anger of Lemieux and others here for people who point this out is amazing, especially because the similarities between the three plans are not really significant. The ACA, regardless of its origins, is what it is: a combination of expanded Medicaid (in some states), penalties for not buying health insurance, and a taxpayer-funded subsidy of the insurance industry. The legislation produces winners (some poor people, middle class children in their early and mid-twenties, people with pre-existing diagnoses, insurance companies, pharma) and losers (middle class people, taxpayers, possibly providers), but its main effect will be to accelerate the expansion and eventual breakdown of our bloated, too-expensive, profit-driven health care delivery system.

Website design incompetence is just a sideshow. The real crisis will begin a year from now when insurers say they need to raise their rates for scaled-down ACA coverage because, despite their vigorous (and expensive) efforts to game the system by limiting access to care and passing costs on to customers, they still didn’t make enough money in 2014. This will be happening just as working poor people begin to understand that the coverage they are forced to buy is likely to leave them owing much more than they can pay if they develop a serious medical problem.

Obama loyalists, like those at this site, will remain committed to denying that there are problems with ACA and ready to go down with the ship, blaming Obama haters on the left and the right as it sinks. When this happens, the ACA’s linkage to Obama and Democrats will discredit not just liberals and the Democratic party but also the idea that real progressive reforms might be able to address serious national problems.

Malaclypse

As most people know, Obamacare is a variation of the Massachusetts plan, which is a variation of the Heritage plan.

Did you not read the post, or do you not understand the words?

bobh

I read it and found it silly.

Scott Lemieux

As most people know, Obamacare is a variation of the Massachusetts plan, which is a variation of the Heritage plan.

The ACA is indeed close to the plan passed by Massachusetts Democrats. It’s not at all similar to the Heritage Plan.

in some states

Yes, damn Obama for forcing the Supreme Court to create new law to strike down the mechanism for the Medicaid expansion! And, surely, many states will turn down the new money forever just like they did with the first Medicaid.

I note as well that you dishonestly left out the ACA’s extensive regulation of the health insurance industry, which presumably is one reason for your foolish argument that the ACA is a mere “variant” of the vastly different Heritage proposal.

especially because the similarities between the three plans are not really significant.

Indeed!

Obviously, there’s no particular need to respond to the completely baseless ipse dixits that comprise the rest of the post.

Scott, John Chaffee proposed the Massachusetts plan. So did Arnold Schwarzenegger. You are right that it isn’t a purely Republican plan, but you are spinning to the point of gross dishonesty when you make it sound like the work of “Massachusetts Democrats”

Scott Lemieux

John Chaffee

Citing John Chaffee as a typical Republican — even in 1993, let alone 2013 — is an act of almost farcical bad faith,like saying that George Wallace is a typical Great Society Democrat. The idea that a nominally Republian senator who couldn’t win a GOP primary anywhere in the country now introducing a bill with some similarities to the ACA somehow makes it a “Republican plan” is utterly absurd.

Some isolated moderate Republican proposing a plan which was mostly developed by Democrats doesn’t get ownership, do they?

And what does ownership mean, here? The question is where the ACA falls on the politics spectrum and by this I mean “is it something that a given party would seriously pursue”. Is there a Republican congress of the last 40 years that would pass anything close to the ACA? Or even get a reasonable amount of support for? I don’t think so.

That doesn’t necessarily make it particularly good or particularly left, but it strongly supports that its not a “Republican plan”.

Scott Lemieux

Is there a Republican congress of the last 40 years that would pass anything close to the ACA?

And this isn’t a hypothetical. There have been substantial periods of unified Republican government during this period. The Republican offer on health care reform is “nothing,” whatever John Chaffee introduced notwithstanding (and leaving aside the fact that citing Chafee as a representative GOP senator is like citing David Souter is a representative GOP judicial appointment.)

Malaclypse

He’s also dishonestly leaving out the “malpractice reform” in Chafee’s proposal.

bobh

The ACA is indeed close to the plan passed by Massachusetts Democrats. It’s not at all similar to the Heritage Plan.

The three plans are similar with variations. All are designed to give some insurance coverage to uninsured people while preserving the key elements of our for-profit health care system. Most people know this. You shouldn’t get upset when someone points it out.

Yes, damn Obama for forcing the Supreme Court to create new law to strike down the mechanism for the Medicaid expansion!

I favor Medicaid expansion. It was one of the good things in the law. You are just being hysterical (!) when you suggest that I support the Supreme Court’s restriction of this part of the ACA.

I note as well that you dishonestly left out the ACA’s extensive regulation of the health insurance industry,

No dishonesty, but see Dilan’s comment below on this subject. One man’s extensive is another man’s ineffectual. Obama’s people worked closely with insurance industry lobbyists to create this mess, and its regulation of the industry interferes very little with their ability to continue extracting huge profits from our national health care system. Look at the stock of these companies since the law was passed. Look at this:

especially because the similarities between the three plans are not really significant.

Indeed!

Again with the exclamation points. If we were talking about this in a bar, would you be shouting at me? Would your acolytes be backing you up there too? Any similarities or differences between the three plans are not relevant to the ACA’s merits. Obamacare is what it is, however much it resembles some other plan. Get it?

Obviously, there’s no particular need to respond to the completely baseless ipse dixits that comprise the rest of the post.

Wow, Latin. I was sharing my thoughts about what I think will happen. They may be ipse dixit, but they are not baseless. We shall see if they are accurate.

The constant, uncritical agreement of the Obama loyalists at this site are interfering with your ability to think clearly.

Continuing to assert this transparent lie doesn’t make it true. The ACA is not a mere “variation” on the Heritage Plan, any more that the Civil Rights Act of 1964 was just a “variation” of the Civil Rights Act of 1957. If the ACA was replaced with legislation that effectively eliminated employer insurance, compelled people to buy nearly unregulated catastrophic coverage and made it impossible for the non-wealthy to obtain anything else, made Medicaid worse rather than expanding it and voucherized Medicare, this would be a radical change in the law, not a minor one.

I favor Medicaid expansion. It was one of the good things in the law. You are just being hysterical (!) when you suggest that I support the Supreme Court’s restriction of this part of the ACA.

I said or implied nothing of the kind. I said that it’s ridiculous to imply that the incompleteness of the Medicaid expansion was a flaw in the legislation, when the legislation in fact anticipated the problem and had its solution rejected by the Supreme Court, one of the many institutional constraints that work against progressive reform in the United States and that puddle-deep critiques of the ACA inevitably ignore.

No dishonesty, but see Dilan’s comment below on this subject. One man’s extensive is another man’s ineffectual.

The law creates clear, enforceable statutory rights that vastly improve the situation for consumers. By the same logic, we shouldn’t care if the Clean Air Act is repealed because regulators may not be able to cover 100% offenders. And the stock prices of insurance companies are not, in fact, evidence, that courts will ignore black letter law.

bobh

Scott,
People who disagree with you about subjective matters, like the degree of difference between and the applicability of the word “similar” to the three plans, or what might have happened if a different president had pursued a different course five years ago or what what will happen in the future because of the problems in our health care system that Obamacare entrenches, are liars. You pretend to bring proofs and evidence to this discussion but you don’t. All you bring is your own certainty.

Scott Lemieux

Well, if you think that it was possible to get 60 votes in the Senate for single payer in 2009, or would consider replacing the ACA with a plan requiring people to purchase unregulated catastrophic insurance while destroying Medicare and Medicaid as merely a minor “variation,” you’re welcome to these beliefs, and I can’t blame you for not being willing to defend them further. I stand by all of my arguments.

bobh

Read what you just wrote. You ignore what I say, build up two straw men,knock them over and strut away. At least you didn’t call me a liar this time.

Scott Lemieux

It’s not a strawman — they’re both logical extensions of your arguments. If the ACA “entrenched” the health insurance industry, this implies that eliminating it was plausible. If the ACA is just a variation of the Heritage plan, then replacing the former with the latter is logically just a mere variation, not any kind of fundamental change.

like the degree of difference between and the applicability of the word “similar” to the three plans,

If this is subjective, then it can’t be mobilized as part of a critique of which is better. But how is it subjective anyway? Either we have a metric of comparison or we don’t.

And did you claim it as subjective? Lets see:

The three plans are similar [ed: not “seem to me to be similar”] with variations. All are [ed: not “seem to me to be”] designed to give some insurance coverage to uninsured people while preserving the key elements of our for-profit health care system. Most people know [ed: not believe!] this.

Yeah. Subjective. Right.

or what might have happened if a different president had pursued a different course five years ago

How is this “subjective”?

or what what will happen in the future because of the problems in our health care system that Obamacare entrenches

Again, this seems like the kind of thing one can mobilized evidence for or get wrong. I.e., not subjective.

are liars

Well, if you are going to claim that all those non subjective things are subjective and thus immune to criticism, then you are either seriously confused or dishonest. At this point, I have to say, it looks a little dishonest.

You pretend to bring proofs and evidence to this discussion but you don’t. All you bring is your own certainty.

Actually, Scott was way more concrete in the points of dissimilarity and also gave a reasonable analogy. In contrast, all you have is bare assertion plus the barely asserted assent of most people.

Projection! It’s not pretty.

bobh

Bijan,

It seems to me that what you are trying to say is that all people who think the three plans are “similar” are wrong and that Scott has somehow proven this. It seems to me that this is not at all the case. It seems to me that the quality known as “similarity” is in the eye of the beholder and is inherently subjective. Just my opinion, of course.

bobh

Same with other unprovable things, like what might have happened under different circumstances or what will happen in the future. It seems to me.

It seems to me that what you are trying to say is that all people who think the three plans are “similar” are wrong and that Scott has somehow proven this.

I (and others) are saying something much more specific.

In general, we pick a similarity metric according to the purpose. For some purposes (e.g., determining the number of male academics overall), Scott and I are so similar as to be identical. For other purposes (e.g., determine the proportion of male to female academics in computer science), we’re completely dissimilar.

The question family we’ve been debating is “Is the ACA essentially a Republican plan?” (and thus, rather bad, non-left, etc.) One facet of this discussion is whether the ACA, in its actual content, is sufficiently close to the Heritage plan as to be reasonably indistinguishable from a policy outcome perspective. (It’s undeniable that no Republican congress (much less unified Republican government) remotely made any progress toward enacting a Heritage esque plan, so we can’t really use “willingness to enact” as a measure.)

There are clearly points of similarity, but a lot of these are merely facial. E.g., the Heritage plan and the ACA both have an individual mandate. But if Stu is correct, they are rather different. They both mention Medicaid, but one to destroy it and one to expand it.

It seems to me that this is not at all the case. It seems to me that the quality known as “similarity” is in the eye of the beholder and is inherently subjective.

But this is obviously wrong. There are some *metrics* which are subjective (e.g., satisfaction with). Furthermore, care much be taken as to the significance of a degree of similarity. Finally, we might not have fully accurate measurements of some features (e.g., because they are estimates or projections). But the differences that Scott is pointing at are mostly not of that sort, at least, to any reasonable degree.

Just my opinion, of course.

But your opinion is wrong. And, indeed, a bit silly. I can say that “Well, the ACA and the NHS are the same!” and, indeed, by some similarity function they are. That doesn’t make that similarity function analytically useful.

Same with other unprovable things, like what might have happened under different circumstances or what will happen in the future. It seems to me.

The fact that there are uncertainties does not mean that all projections or counterfactuals are created equal. There are methodologies! Techniques! Standards of evidence!

And obviously you believe this or you wouldn’t be able to critique Scott for his “certainty”.

Are we really playing Intro to Philosophy annoying student plays the “it’s my opinion! how can you critique” game?

Hint: They’ve lost by starting.

bobh

Bijan,

I think an impartial observer, a rare bird around here, would agree with me that you don’t understand the meaning of the word “subjective.”

Also, you appear to believe that “not remotely similar” is a close variant of “[not]reasonably indistinguishable from a policy outcome perspective.” I’m not sure what “reasonably indistinguishable” means, but I will stipulate that the three similar (in my view) health care plans are, in fact, distinguishable from a policy outcome perspective.

It also seems as if you are the one who got stuck in Intro to Philosophy. (But maybe you just talk that way naturally.)

Again in my opinion (please feel free to insert more “in my opinions” anywhere you like if my certainty begins to approach your’s and Scott’s), Obamacare is a complicated mess, largely due to important similarities with both the Massachusetts and Heritage plans, including the fact that the most dangerous shortcomings of all three stem from a need to preserve the freedom of the insurance industry (and other industries) to exploit our health care system to enrich themselves.

There are, I will further stipulate, differences between the three plans, some of which you and Scott have mentioned.

I can’t be certain what possibilities for future meaningful reform existed in early November, 2008, when (in my opinion) Obama dropped his progressive pretenses and went all-in with the pro-corporate, pro-bank, pro-elite wing of his party, but neither can you. Neither can Scott or other Obama loyalists who now insist he had no choice but to get us into the mess we face today.

Today, in my opinion, we face a likelihood that ACA shortcomings will accelerate an ongoing national crisis in health care delivery costs. Because Obama is a Democrat and is thought by many to be a liberal, a progressive or even a socialist, this crisis is likely to discredit Democrats, liberals, socialists and, worst of all, any thought of using genuine progressive/left reforms to address serious national problems. This nuclear winter for progressives could last for several election cycles. This possibility worries me, and that worry is what motivates me and others who disagree with you to speak out and even wonder whether Obama’s re-election may not, in fact, turn out to have been “the lesser of two evils.” What does not motivate me at all is a neurotic need to be more left-wing than you.

I have had my say and don’t think I will be back here for a while. You may now have the last word. Hint: so far, you are not distinguishing yourself in your quest for Scott’s approval (in my opinion).

Bijan is straight up (with the possible exception of Aimai) the most thoughtful and fair minded commenter on this fucking site so I don’t know what the hell you’re talking about, ball-taker, but whatever it is it’s super wrong.

junker

I was just about to post that! Right on Sharculese.

Scott Lemieux

I can say that “Well, the ACA and the NHS are the same!” and, indeed, by some similarity function they are. That doesn’t make that similarity function analytically useful.

For that matter, a health care plan that guarantees everyone a bottle of aspirin a year can be seen as “similar” to the NHS, because they’re both health care policies. Clearly, whether these plans are truly similar is just a matter of subjective opinion!

I think an impartial observer, a rare bird around here, would agree with me that you don’t understand the meaning of the word “subjective.”

I imagine you do so think, but you think a lot of kooky things. Since you didn’t articulate what you think is wrong with my bog standard mobilisation of the term (as opposed to your wildly incorrect use which seems purely motivated to shield you from criticism), so I have no idea what you think the objective observer would say. But I assure you, they would say that you’re bonkers.

Also, you appear to believe that “not remotely similar” is a close variant of “[not]reasonably indistinguishable from a policy outcome perspective.”

No. Not remotely similar would be something like “quite different in their policy outcomes”.

I’m not sure what “reasonably indistinguishable” means, but I will stipulate that the three similar (in my view) health care plans are, in fact, distinguishable from a policy outcome perspective.

It also seems as if you are the one who got stuck in Intro to Philosophy.

Nope. Got my PhD an everything. So not stuck there! And I moved into computer science, so not even stuck teaching it. But I do remember people like you.

(But maybe you just talk that way naturally.)

Both by nature and training.

Again in my opinion (please feel free to insert more “in my opinions” anywhere you like if my certainty begins to approach your’s and Scott’s),
It clearly surprasses it.

Obamacare is a complicated mess, largely due to important similarities with both the Massachusetts and Heritage plans, including the fact that the most dangerous shortcomings of all three stem from a need to preserve the freedom of the insurance industry (and other industries) to exploit our health care system to enrich themselves.

This is at least an articulated similarity function. Great! Unfortunately, it’s probably wrong since both the MA plan and the ACA have a much greater regulatory regime. You might want to argue that its insufficient, but you have to actually do it.

There are, I will further stipulate, differences between the three plans, some of which you and Scott have mentioned.

Great!

I can’t be certain what possibilities for future meaningful reform existed in early November, 2008, when (in my opinion) Obama dropped his progressive pretenses and went all-in with the pro-corporate, pro-bank, pro-elite wing of his party, but neither can you.

But we can look at the available evidence. Oh, and it’s not so very helpful to make it about Obama’s psychology. Who cares, really? The question is what was the possible range of policy options. From the Republicans, clearly, unambiguously, there was nothing. Certainly not with Obama in power. From the Dems, we have Bernstien’s observations about the primaries and we have the actual gatekeepers, the most conservative Democratic senators. We know that Lieberman killed Medicare buy in right after championing it. My interpretation of these events is Lieberman was not going to support a much more progressive or less insurance friendly bill, straight up. And without Lieberman, there’s no passage of a bill. So what’s your counter? What scenario gets us Lieberman with Medicare for all?

Neither can Scott or other Obama loyalists who now insist he had no choice but to get us into the mess we face today.

I do appreciate you slipping in the little “Obama loyalist” lines! It helps establish your credibility.

However, throwing you hands up in the air and saying “Who knows? I have no idea!!” should produce silence, not the claims you’ve made. And, in point of fact, while not 100% (due to the limitations of historical and poly sci arguments) the case in incredibly strong that nothing similarly comprehensive yet more progressive could have been passed. The case against is, thus far, exactly nothing.

Today, in my opinion, we face a likelihood

A very low one.

that ACA shortcomings will accelerate an ongoing national crisis in health care delivery costs.

Which will have to start some time in the future because thus far it (and the recession) have dramatically slowed the growth of health care costs. (And the ACA has directly had effects e.g., increasing the use of fee for quality.) But keep your fingers crossed!

Because Obama is a Democrat and is thought by many to be a liberal, a progressive or even a socialist, this crisis is likely to discredit Democrats, liberals, socialists and, worst of all, any thought of using genuine progressive/left reforms to address serious national problems.

Your concern is touching.

This nuclear winter for progressives could last for several election cycles.

If you say so.

This possibility worries me, and that worry is what motivates me and others who disagree with you to speak out and even wonder whether Obama’s re-election may not, in fact, turn out to have been “the lesser of two evils.”

Because heightening the contradictions would have been better! Great!

What does not motivate me at all is a neurotic need to be more left-wing than you.

Er… the last paragraph was, almost definitionally, an expression of a neurotic need to be more left wing than me (or more politically savvy). It’s a cool variant though!

I have had my say and don’t think I will be back here for a while. You may now have the last word. Hint: so far, you are not distinguishing yourself in your quest for Scott’s approval (in my opinion).

Fun attempt to play psychologist! It’s about as good as your political analysis.

I was pondering what bobh could possibly mean by “subjective” and I developed a theory.

Consider a fair coin toss. Before the toss our evidence that it will turn up heads or tails is 50%. If forced to bet on the outcome it simply does not matter which one you pick. Thus, if so forced, you are free to choose either without fear of critique: Even if you are wrong, there was no better choice you could have made in the situation you were in. Thus, in some circumstances, uncertainty leaves to free to make the call however you like.

Now, this freedom doesn’t make the choice “subjective”, technically speaking, merely “as good as” any other choice.

Now a subjective judgement (e.g., whether you like the color green over the color blue) is similarly immune* to criticism: It’s not wrong to prefer green to blue in the sense that someone could produce critical evidence against it.

So, I’m guessing, bobh wanting the immunity to criticism of subjectivity, just decided to claim plan similarity judgements are subjective.

* Technically, one certainly can have incorrect *expressions* of preference (e.g., by lying). More sophisticatedly, we can be mistaken in a variety of ways about our inclinations as implicit bias research shows. However, we’re free to claim preference safely.

I’m going to use the fact that I haven’t seen him post in a while as my excuse for neglecting him.

joe from Lowell

Whether two plans are similar is not a subjective matter.

I think I see the problem here.

andrew

My very decent HSA policy is being cancelled due to the ACA. With a family out of pocket of only 5K for a family of four, and a cost of about 1000 per month, I will now be forced to pay about 1350 per month with a family out of pocket of 12,500 before I collect a penny. So 16K in premiums per year. 12,500 medical charges for a total cost of 28,500 per year before I collect dollar one from the insurer. And this is supposed to be affordable or better than a catastrophic policy somehow?

Paula

No: i’ve just given them money to purchase something much better than they had before. “Paying for a few appointments”, which you deride, is key to public health. People don’t need to fear seeking medical advice and consultation, because they can afford it, and if the news is bad they’re still covered against truly extraordinary expenses (much, much better covered than under “catastrophic coverage”), and they’re informed enough to act enough to act early and responsibly

It kind of amazes me that this has to be re-stated on a liberal blog. To people who are protesting their own liberalier-ness on health care reform.

I would add, key to public health and keeping costs down over the long term, because fewer people resorting to the emergency room at the last minute for something serious. Do these people know how much money can be eaten up by a few nights at a hospital and few tests, let alone something that requires surgery or extensive treatment?

I had catastrophic before Obamacare, since i am healthy and take care of myself, hardly ever go to the doctor’s. Now my premiums have shot up 50% suddenly- is that what was supposed to happen? don’t think so!